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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORTER'S COMPENSATION INSURANCE AF { AVTT
Oijperniittee)
with a principal place of business/residence at:
(phone#)
(streei/citylstafr/�ip)
do hereby certify, under the pains and penalties of penury, that
( an employer providing the following worker's compensation coverage for my
employees working on this job:
�,9�r`Z,. �s�,�/may r,✓� �'� G �Sr�'y? ��i G�
(Insu as Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (insurance Company/PoUcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Coatracior) (Insuran(-- CompaDy/policy Number) (Expiration Date)
(Name of Contactor) Gmsu=ce Company/Policy Number) (Expiration Date)
(attach zdditiocial shed ifntr ry to include iaforaution pertaining to all axdr rs)
i
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:ptcaac lx aware that whidc homco"ixri who crnplay periaw to do rnxn�oxzt,C.Oci err rrPair work on a of
not more than thrca units in�c nch the lwn»oaver 1,=dca or oa the grounds appurttnani the:do arc n«ecnrnrly coax datd to be
employers under tho tvockces Act(GL152—:51(5) appdcaEoo by n homoovma for a liccase cc permit may evidcnx the
legal status of an employes under the Woric.ele Compoonation +eL
I understand that a copy of thin statrmmi m.y bo forwarded to tho DcQwimcod of Aoci&-&Offioc of Inzrirsnco for the
coverage vaificatioa and that failure to accrue oovctago under section 25A of MOL 152 can Icad to the imposition of criminal pcnali(cs
00oustmg of a fmc of up to S 1,500.00 and/or i nprisonnxat of up to one yew and civil pcaalti a in the form of a Stop Work Order and a
find of s 100.00 a day against tae..
Foe dqi uinl er city
Permit t N Number
MaI Lot#
,,,'.: Signature of Liccnsee/permitfee e
SECT'ION,$3z C'ON5;�Rl�ClO�N S`ERVIC�S � ����
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
—7 License Number
Address Expiration Date
Signature Telephone
rR Not Applicable ❑
/ a 1 s32
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'..COMPENSATION INSURANCE AFFIDAVIT'(M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affica
will result in the denial of the issuance of th building permit.
Signed Affidavit Attached Yes....... No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)familie
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780 Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,You may be liable for person(
you hire to perform work for you under this permit.
The undersigned"homeowner" certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
' I
ss� Ji-�vy'r�
SON 5 DESCRIPTION OF PROPOSED WORKS{c
EC TI ik allanalicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: ��� S �4 A,y
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative F] Renovating unfinished basement Yes -° Nq
Plans Attached Roll ❑- Sheet❑
..If a ew ho see-a" d or acldit'on to exls 1 ff o MM—ft comILIble thM-0J '0"WJb !:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
h. Type of construction
,K! i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a,-OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS-AGENT OR,CONTRACTOR APPLIES'FOR t3UILDING PERMIT
as Owner of the subject proper
hereby authorize to act
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I,
, as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
��E' �i'trE✓J�`�
Print Name
Signature of Owner/Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO �1 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
rr�, f----- of Northampton k at -
t� i ding Department Curb emu`It
12 Main Street :Sewe p a
J�; i Room 100 1NaterlWei1 1 _
AR 2002 i Two,S
,'ampton, MA 01060 y.
:6 ° a•
3-5 7.1240 Fax 413-587-1272 �51te
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORATI
MON
Thii
I.J. Property Address:
$ � j
Map of ..
r
Elm
istnct � ° � CBS i r cf" fi£
SECTION 2 - PRO PERT-Y OWNERSHIP%AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing ddress:�8�s
S� —
.� Telephone
Signature
2 2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION;'3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Uso Only
completed by ermit applicant
1. Building Summa (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building PermitNumber: . Date Issued:
natu ee
Building Commiss•IR er�lnspector of;BptJ,d�nBs Date,
:S HILLCREST DR BP-2002-0823
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-302 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2002.0823
Project# JS-2002-1373
Est.Cost: $5000.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Roy Omasta 101533
Lot Size(sq. ft.): 21867.12 Owner: TURNER DAVID S &MELODIE P
Zoning:URA Applicant: Roy Omasta
AT. 115 HILLCREST DR
Applicant Address: Phone: Insurance:
21 North St (413)247-5666 Workers Compensation
HATFIELDMA01038 ISSUED ON:411102 0:00:00
TO PERFORM THE FOLLOWING WORK:SHINGLE ROOF OVER SINGLE LAYER
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy SiEnature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 4/1/02 0:00:00 12666 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo